Form 0923-0048 Anaconda MT Exposure Investigation Questionnaire

Form Approved

OMB No. 0923-0048

Exp. Date 03/31/2019

Attachment 4:

Anaconda MT Exposure Investigation Questionnaire

Flesch-Kincaid Level – 5.4

[The interviewer will not state “don’t know” and “refused” as response options, The interviewer will mark such responses only if provided by the participant. This holds true to all questions, including ethnicity and race.]

Introduction - Hello my name is {SAY NAME}.

We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. ATSDR is a sister agency to the Centers for Disease Control and Prevention (CDC). As part of the investigation, we will be asking you some common questions like your name and address. We will also ask questions on your contact with lead and arsenic. We are asking these questions to better understand all the data we collect.

The questions should take about 20 minutes. After that, we will be offering free blood and urine testing for participants in this exposure investigation. Your total time in the investigation will be about 30 minutes. Once we are done with this investigation, you will be given a copy and details of the testing results for you and your children (if you have them). Generally, we are able to get results to you within 12 weeks.

Cost Recovery Number: 8018

1. Person Administering Questionnaire ­­­­­­­­­­­­­­­­­­­­­­_______________________________________

2. Date Questionnaire Administered _________________________________________

3. Participant last name ___________________________________________________

4. Participants first name __________________________________________________

5. Address: _____________________________________________________________

______________________________________________________________

______________________________________________________________

6. Mailing address if different from home address: ______________________________

______________________________________________________________

______________________________________________________________

7. Laboratory ID ________________________________________________________

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0048).

Now I want to ask you questions about how I can contact you. I will also be asking how long you have lived at or visited certain places. This is needed to find out how long you may have had contact with lead and arsenic and how long it may have lasted. We will also ask your age, address, race, and about how you spend your time (e.g, child at daycare, how often they play outside, your jobs and hobbies). This is useful to help us better understand your test results.

8. Is the person being interviewed a minor?

Yes

No (skip to question 17)

9. Name of person answering questions for minor child:

10. Relationship to child:

Mother

Father

Grandparent

Guardian

11. Has your child ever had their blood tested for lead?

Yes

No (skip to question 13)

12. If yes, when, where and what was the result?

13. Does the child put their hands or toys in their mouth?

Yes

No (skip to question 21)

14. If yes, what and how often?

15. Have you noticed the child eating dirt while playing outside?

Yes

No (skip to question 23)

16. If yes, how often?

Demographic Questions. Script: The next questions are about qualities of the person who is being tested (you or your child/ward). This information and will help us better understand your test results.

17. What is your or your child/ward’s sex?

Male

Female

18. What is your or your child/ward’s age and date of birth?

Age

Date of Birth

19. Are you or your child/ward Hispanic, Latino/a, or Spanish Origin?

No, not of Hispanic, Latino/a, or Spanish origin

Yes, of Hispanic, Latino/a, or Spanish origin

20. What is your or your child/ward’s race? One or more categories may be selected.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

21. If female between 15-44 yrs, are you pregnant? If yes in what month of pregnancy?

Don't know

No

Yes, 0 to 3 months

Yes, 4 to 6 months

Yes, 7 to 9 months

22. Do you or your child/ward spend time outside the home (e.g., work or daycare/school)?

Yes

No (skip to question 25)

23. If yes, how long are your or your child/ward out of the house during the day?

1 to 4 hours

5 to 8 hours

Over 8 hours

Don’t know

24. If you or your child/ward are out of the house during the day, how many times per week?

1-3 days per week

4 or more days per week

Don’t know

25. How many hours per day do you or your child/ward typically spend outdoors?

Do not spend time outdoors

Less than 2 hours per day

2 to 4 hours per day

4 to 6 hours per day

Over 6 hours per day

Don’t know

26. How many hours per day do you or your child/ward typically spend in your attic?

Do not spend time in the attic

Less than 2 hours per day

2 to 4 hours per day

4 to 6 hours per day

Over 6 hours per day

Don’t know

27. Does you or your child/ward wash hands before eating?

Always

Sometimes

Never

28. How long have you lived at this address?

Less than 6 months

6 months to less than 2 years

2 to 5 years

6 to 10 years

More than 10 years

29. How long have you lived in Anaconda, MT?

Less than 6 months

6 months to less than 2 years

2 to 5 years

6 to 10 years

More than 10 years

30. Do you speak a language other than English at home? (5 years or older)

Yes

No (skip to question 32)

31. If you speak another language in the household, do you prefer receiving followup information in another language? What is this language? (5 years old and older)

Yes, Spanish

Yes, Other __________________________

Attributes of the Structure or Home. The following questions are about the qualities and characteristics of your home.

32. Do you live in a(n):

Apartment

Single Family Home

Townhouse or Condominium

Mobile Home

Other

33. Approximately when was the building built?

2000—present

1990—1999

1980—1989

1970—1979

1960—1969

1950—1959

1940—1949

1939 or earlier

Don’t know

34. What is the condition of your home or building?

Good

Fair

Poor

35. Do the windows (e.g., sills) have peeling paint?

Yes No

36. Is there peeling paint in other places such as cabinets, interior walls and/or exterior walls?

Yes

No

Don’t know

37. How often do you clean your home using a wet mop?

Daily

Several times a week

Weekly

Monthly

Other

38. How often do you clean your home using a vacuum cleaner?

Daily

Several times a week

Weekly

Monthly

Other

39. Do you have an attic in your home?

Yes

No (skip to question 42)

40. If you have an attic in your home, how often do you enter the attic?

Daily

Weekly

Monthly

Yearly

Never

41. Has your attic been cleaned by a professional?

Yes

No

42. If yes, when was it cleaned?

Soil Information (Tracking inside home)

43. Does your home have a yard with bare dirt?

Yes

No

44. Has soil in your yard been removed and replaced with clean soil?

Yes

No (skip to question 46)

45. If yes, when was it done?

46. How often do you or your child/ward remove shoes before entering your home?

Never do this

Seldom do this

Sometimes do this

Always do this

47. Does anyone in the home work primarily outdoors in a job with frequent soil or slag contact? (slag reprocessor, construction worker, landscaping, etc.) (if NO, skip to question 49)

Yes

No

Don’t know

48. How often do they change clothing when entering the home after work outdoors?

Never do this

Seldom do this

Sometimes do this

Always do this

49. Do you have a job that may bring you into contact with lead?

Mechanic

Transportation worker

Construction worker

Other

50. Do you have a job that may bring you into contact with arsenic?

Wood preservation

Arsenate pesticide production

Sand blaster

Other

Other Sources of Lead Exposure

51. Have you or your child/ward used any Mexican pottery in the past month?

Yes

No

Don’t know

52. Have you or your child/ward used any home (folk) remedies (used in Indian, Asian and Hispanic cultures) in the past month for any illnesses?

Yes

No

Don’t know

53. Have you or your child/ward eaten any Mexican candy (containing chili powder or tamarind) in the past month?

Yes

No

Don’t know

54. Do you or your child/ward own any imported toy or costume jewelry that are over 10 years old?

Yes

No

Don’t know

55. Do you or your child/ward have any hobbies that may involve exposure to lead?

No

Don’t know

Stained Glass

Firing Range

Leaded fishing lures

Other (list out)

Frequency of Eating Food That May Contain Arsenic

56. How many portions of fish and other seafood (including shrimp) did you or your child/ward eat in the past week?

None

1-2

3-4

5 or more

Don’t know

57. How many portions of rice (white or brown) did you or your child/ward eat in the past week?

None

1-2

3-4

5 or more

Don’t know

58. How many portions of chicken did you or your child/ward eat in the past week?

None

1-2

3-4

5 or more

Don’t know

59. Is there anything you want us to know about you or your child that we did not ask about?

2